Comments

Terence, I want to clarify that Sam's article was not written on the premise that there has been a decision to partner with Coke. Coke has been used by donors elsewhere, it got a favourable mention from the Minister, and Sam was analysing whether the Australian aid program should partner with Coke in the Pacific, not critiquing a decision to partner with it.

Thanks for this well-balanced and considered article – much more constructive than some of the ‘kick-back’ commentary we see, which actually stifles proper debate. It is important to keep an open mind and be prepared to think the unthinkable when you are faced with stubborn global health challenges, as you never know where this might lead you. We have to acknowledge that some of the current approaches to improving access to medicine are not working and haven’t worked for many years. Access to diarrhoea treatment in Africa is one example. In these circumstances we have to ask: do we carry on doing what we’ve always done or do we seek to innovate and try other approaches? On the basis that it’s easier to act your way into a new way of thinking than think your way into a new way of acting[1], ColaLife did the unthinkable and designed a diarrhoea treatment kit – called Kit Yamoyo - that fitted in the unused space in Coca-Cola crates. The logic was simple: Coca-Cola gets everywhere so if medicines went with it, they would get there too. From a standing start and within 12 months we’d got diarrhoea treatment rates up from less than 1% to 45% in the two remote trial areas in Zambia. And this is for an international standard treatment that has been around for 10 years. The big surprise was that only 4% of the 26,000 kits sold actually travelled to remote communities in Coca-Cola crates. This was not the innovation we thought it was. It wasn’t the space in the crate that was important, it was the space in the market. What the folks at Coca-Cola taught us was how to design a product together with its value chain. That’s what they do with a brown fizzy drink. We learnt this and applied the same principles to a health product with potentially game-changing results. Following the trial, we are now working with the local manufacturer of Kit Yamoyo in Zambia to establish it in the market, while in parallel, and inspired by our work, the Government of Zambia have ordered 452,000 ‘unbranded’ kits to be given away free through health clinics in 11 of the most nutritionally deprived districts in Zambia. These alone will save 1,350 lives if the ‘lives saved’ modelling done for our trial holds true for the scale-up. The key points to note from our experience are: 1. We would not have made the progress we’ve made if we’d shut down the possibility of talking to Coca-Cola ‘on principle’. 2. During our trial and during the scale-up there is no association between our anti-diarrhoea kit and Coca-Cola. None of those involved in the marketing, distribution and sale of Kit Yamoyo have any idea that we are mimicking the drinks giant’s methods. Kit Yamoyo doesn’t even carry ColaLife branding let alone Coca-Cola branding. Coca-Cola’s involvement in Tanzania and Ghana with the national essential medicines distributors is also advisory. They are helping the existing organisations responsible for the distribution of medicines in the public sector to become more efficient and effective. They are building local capacity, they are not ‘taking over’ the distribution. And that brings me to my final point and a key area of general misunderstanding. Many fall into the trap of assuming that the Coke they see in remote places is taken there by Coca-Cola and therefore attribute Coca-Cola with having the most amazing global distribution system. The truth is that if you go to any of these remote places you will never see a Coke truck or van. Coca-Cola is brought to these remote communities by independent micro-retailers and entrepreneurs and they bring it because people want it and they can make a profit selling it to them. The system works by clever product design and marketing and the creation of a value chain which ensures that everyone who touches the product on its journey to consumers makes a profit and the target customers can afford it. Obviously, you can only apply these principles to a health product if that product can be ‘commoditised’. Fortunately, you can do this for an anti-diarrhoea kit but you couldn’t do it for the majority of medicines. However, that doesn’t mean that you can’t use existing private sector channels to get more complex medicines to trained health personnel in remote communities and you can read ColaLife’s thoughts on this <a href="http://www.colalife.org/2013/03/08/could-the-private-sector-supply-remote-rural-health-posts-in-zambia/" rel="nofollow">here</a>. Again, although this idea is inspired by the ubiquity of Coca-Cola it can be implemented with no reference to The Coca-Cola Company. Sure, let’s be aware of the ethical issues but let’s keep an open mind and consider all possible options when it comes to improving the health of some of the poorest people on the planet. Simon Berry CEO ColaLife

Thanks for the article. I'm not sure where I read the phrase "PR master move" in relation to the original "$1 a day" global poverty line, but it is definitely apt. The power of this statistic its that it is so easily understandable and communicable. The establishment of the new commission is a direct result of this success, and is very welcome. But as important as technical correctness is, I hope that simplicity will not be sacrificed for nuance.

For me, I think ultimately it comes down to the fact that distributing medical supplies through a system like Coca-Cola's is a great solution for the short-term. For the long-term, however, we need to be investing in building robust supply systems that do not require support from producers with potentially questionable interests.

Very well said Garth. The health strategy is about building health systems. Using Coke's distribution networks might be a quick fix but does nothing to build strong systems in the Pacific. Great blog Sam - a very good read. The thing that I would add is that the whole "let's use Coke to distribute medicines" thing was a big deal in the African ART context around 2006. The Australian government is just getting on to this in mid-2015...

I am sure that one of the most important options to help develop emerging societies is to democratize their governments, in these directions: empowerment of women, transparency in the use of the economical resources given, rendition of clearly use of the resources, caring of the environment, human rights and autosustainability. Otherwise all the amounts of money and human educated resources that they provide to these countries will not achieve their objectives, which in fact is that the purpose of helping those societies to generate jobs, and infrastructure that dignifies the life of such societies, and will in the near future enable those poor countries to avoid expelling their populations as immigrants to the developed countries. Education is the key to develop the society, thus it is very important to improve the educational methodologies to approach the bigger number of children, women and adults who are the ones who should support the development and democracy of the underdeveloped countries, to bring them up, as modern and democratic, just, dignified, self-sustained societies.

Coca Cola is a product available for people to decide whether they want to purchase or not. To change the behaviour of people when it comes to their lifestyle, we should not necessarily be depriving them of that (since, by using this logic, one of the aims of aid in the Pacific could be to prevent Coca Cola, junk food and cigarettes from getting into stores). Instead, we should be helping Pacific Governments to educate people on why deciding to buy Coca Cola or packet of cigarettes is bad for them, and providing support for the emergence of healthier, affordable alternatives.

Thanks Amanda. Your innovation will work well for collecting government information (e.g. in your example of district court clerks), stock supply levels or enrolment figures. We do a lot of research in remote Australian communities to inform policy (as part of the Cooperative Research Centre for Remote Economic Participation (CRC REP)) and I wonder if some of our experiences can add to yours. Most of Australia's remote communities have no mobile phone connectivity, so we use pre-loaded iPads (later downloaded) that are operated by local Aboriginal Community Researchers (ACRs). We have a network of around 200 trained ACRs – who are culturally empathetic and can work bilingually in an inclusive, respectful and genuinely consultative way. They are skilled at working independently or alongside communities and service providers to bring about positive impacts. They are mentored and trained by research leaders from UniSA, UNE, Curtin, CDU, Flinders and SCU. I'm sure PNG could mount a similar capability, even with a bit of help from DFAT (this may already be happening). It isn't easy and it’s expensive on the surface, but it's much more effective and cheaper than using FIFO consultants.

Coca Cola might very well have knowledge and skills which could be useful in improving medicine and food distribution networks in developing countries and I think we should make use of their advice. However Coca Cola's clear contribution to ill health seems to me to make it highly inappropriate and not constructive to link health service delivery to their activities. In addition, if we would not rely on private food companies to distribute medicines here, why would we promote this in other countries? It is clear that many poor countries do run effective health services and drug distribution networks and we should be providing effective assistance to our Pacific neighbours to help them to do likewise.

Hi Sam, Good post. I would add two points: 1. I don't know what parts of the Pacific Minister Bishop has been to, or which hills she has scaled, but Coke was scarce in the parts of rural Solomons I travelled through. Rural health clinics, on the other hand, while under-resourced, were present, could provide first aid, and were possibly the cause of the decline in Malaria that was frequently commented on by people I spoke to. 2. Beyond that: Coke and medicines are, conceptually, two very different things. Coke is a private good (we don't worry too much if people can't afford it); medicines are merit goods (we hope to live in a world where anyone can access the medicines that they need). With private goods it is comparatively easy to leave it to markets to deliver (and if they don't it's not usually the end of the world). With merit goods there is often a need for government subsidies to make sure that everyone has access. But having the government subsidising private delivery networks brings with it accountability and political economy risks of its own. (How do we know the private sector is actually delivering what it says it has? And can we be sure that the potential for profit is not causing it to exert undue influence on what should be technocratic or democratic decisions about distribution?) This doesn't mean we should never engage with the private sector in delivery, but it does complicate matters considerably, particularly in poorly functioning polities. Thanks for a good post on what sounds, at first glance, to be a poorly thought through decision. Terence

Hi Jo, That's a very good question. As you note, DFAT/AusAID has been doing elements of health system strengthening for a long time and the evidence of positive impact in PNG and Solomons is probably limited. The strategy does not directly cite successes from the Pacific. A couple examples of positive results from Indonesia and Cambodia are noted. Others have critiqued the focus on health systems noting that the global results are not amazing - but the Lancet paper tries to address that - and I really don't see any alternative to focusing on health systems. No one ever said it was gonna be easy!

I abhor cuts to Australian Aid but are Afghan health and education programs sustainable in the present security climate?